08 August 2013

As always, I'm going to try to say as much as I can, as briefly as I can.

Man: body and soul. From the Bible I learn that man was created as an embodied soul (Gen. 1—2). He's not a spirit uneasily floating within a body; he's not a body with some higher functions. Being parted from his body is an unnatural and temporary state, which God will ultimately remedy (1 Cor. 15; Rev. 20).

In the meanwhile, here we are, body and soul. Spiritual realities such as guilt and unbelief, as well as faith and hope, produce physical effects (2 Sam. 13:2; Pss. 16:9; 32:3-4; 38:3, 7; 63:1; 119:120), and physical states can effect us spiritually (Pss. 6:2-7; 88:13?). We should humbly admit that there are many mysteries as to the relation of soul and body that we just can't resolve finally. Where is the person, in the body afflicted with

Alzheimers, or laid low in a coma? What is the volitional buy-in when there is what is called a bipolar or autistic pattern? Is it great? Is it nil? Certainty is evasive.

Depression: cause(s) and effect(s). Specifically as to depression, it isn't a single effect with a single cause. Ask David; ask Elijah; ask Jeremiah; ask Spurgeon; ask me. It can grow from unbelief, from exhaustion, from lazy thinking, from persecution, from a dozen, a hundred other causes known and unknown. Professor David Murray, for instance, has recently highlighted some research finding a physical indicator of depression.

Causation gnarliness. However, that said, still — which the chicken, which the egg? Plus, the very splash this story made in part relates to the paucity of such hard evidence (remember: theory, no matter how oft-repeated, is not proof) previously. When I talked to my doctor about the very serious depression I was beginning to experience some decades ago, he told me about the lack of serotonin in my brain, and wanted me to take a pill for it. It turns out that this whole model is (to say the least) not nearly as sure a thing as it is presented.

Now, think about that. Tests determine whether I have blood pressure issues, problems with my heart, lung, brains, nerves, eyes, and on and on. Tests identify the problems, surgery or medicine can address the problems, and tests will disclose whether the conditions are improving or not. With mental issues, emotional issues, behavioral issues? It's not as cut and dried as we're often told by the white coats.

What's depressing me right now is the certainty that, no matter how carefully I'm trying to write, I'm being misunderstood. One group of readers is saying "Aha! Exactly! All those pills and doctors are complete wastes of time! I agree with you!" Another, "I can't believe you're so heartless and ignorant as to banish suffering people back to the Dark Ages. What do you recommend? Leeches, dungeons, beatings?" Neither is a correct reading.

It's...complicated. What I am really saying is that it's complex, it's complicated, and we should proceed with cautious humility. I am saying that stridency of voice is not always an indicator of clarity of evidence. And I'm saying all that to come to this pastoral turn.

Both ways? Not so much. When I counsel people with depression, I find that many have already been to the doctor, and many are already taking medication.

There's a real imbalance in practice, here; a partnership that should be happening but isn't. If a person came to me with serious depression, I would encourage him to get some medical tests to make sure there's not a physical issue. However, I have never yet met one person whose doctor said "There are pills that address some of these symptoms. But since I find no physical cause, I'd like you first to work with your pastor and see if the issue isn't non-physical." Rather, it seems that doctors reach for their prescription-pad faster than James Bond for his Walther PPK.

Altered picture. So in these situations, I start out in a bind. I am, as I said, not opposed in principle to medication. However, it is undeniable that medication changes the equation to some degree, perhaps dramatically. I am dealing with a person who is taking mind-affecting drugs. What he sees and feels is colored, to some degree, by the pills he is taking. NOTE: Truly, I am saying this without the least condemnation of the suffering brother or sister. I simply state a fact.

Some drug is in the picture with which I'm being presented. I have no training in these medications, and have no expertise in dealing with drugs, so... what exactly do I do? How do I proceed?

Are the drugs helping this dear one and me in what we want to accomplish? Or are they hindering? Are they moving us towards a goal, or hiding critical information?

Curing... or masking? Think of it this way: suppose I'm wearing shoes that are far too tight. My feet hurt awfully. I go to the doctor. The doctor wants to help me, he hears I'm in pain. So he prescribes pain medication. I take it, I feel better. And I continue wearing the shoes.

The pills help the pain (that the shoes are causing), but they do other things as well. I'm a bit drowsy, I'm not as sharp-minded. The drug affects my work, it makes driving problematic. And then there's the problem of the law of diminishing effects, as dosage is gradually elevated.

However, the pills were immediately helpful for the pain.

The problem of pain? or of its absence? All of this overlooks the fact that this pain had a purpose, a God-given purpose. The pain was meant to alert me to the problem: my shoes were too tight. The solution was not to address the pain qua pain, but to find the source of the pain. In fact, helping me tolerate the pain — short-circuiting God's flashing red light system — might ultimately cause real damage to my feet.

So this depression... is it a hormonal deficiency? As a pastor, I can't help that by Biblical counseling. Lack of rest? Blood sugar? That's not my area, not my specialty.

But suppose (just suppose! that's all I'm saying) the depression is a result of guilt over sin? or of ignorance of God's truth? or of a faint grip of the truths of God's grace and love and promises? or of lazy unbelief? or of disobedience? These are among the many, many possible causes of depression — not to mention the causeless depression of which Spurgeon wrote. But in all of these cases except perhaps the last, not only will medicating the symptoms away not help, but it will actually retard the process, by hooding God's flashing red light.

Where are we going? And there's more. Invariably, I ask these dear souls what the doctor's end-game is, and invariably they don't know, because he hasn't told them. Does the doctor mean them to take pills the rest of their lives? (Some have already done so for decades.) But then, how can we ever know whether the person is better? One can't stop these medications cold-turkey, that causes its own problems. So where are we going with this, and how do we know when we've gotten there?

In the attempts to bring this post to a close with a useful takeaway, here is a list of questions I'd like anyone to ask his doctor, before he begins taking drugs for depression or such. These should not be combative questions. They aren't meant to be. They should simply help make for an informed patient.

As an added bonus, the answers would be very helpful to the pastor who usually is brought in late in the game.

Ask your doctor:

Do you think my problem is a sheerly-physical problem?

Is there a test that has shown, or can show, whether my problem is a sheerly-physical problem?

How long do you intend me to take these pills? That is, when will I stop?

How will we know when I can stop taking these pills?

Even answers to just those four questions would be so helpful in a counseling situation.

After all, I hope we're all agreed to hold three specific stances:

Our goal in life is to glorify God to the greatest degree possible (1 Cor. 10:31).

We don't want to try to address physical issues spiritually, or vice-versa.

While medicine is a gift from God, we don't want to take either more or less personality-affecting medication than is necessary.

25 comments:

Hi, long-time lurker here. Read most days, violently disagree with half of what you write (theologically I'm somewhere between Nicky Gumbel and Rachel Held Evans!) and the other half cuts me "to the separating of bone and marrow", i.e. in a very good way.

First let me say that you've written here with a clarity and care that isn't seen as much as we'd like on the Internet, and for that I really, really thank you. That's a pastor's heart, right there.

I'm in the UK, where more doctors are unwilling to prescribe drugs for depression and many - probably the majority - will prescribe drugs AND counselling or CBT or just good old-fashioned "dude, TALK to someone about this stuff" as well.

(Of course, over here medical treatment is publically funded, and whatever you may think about that, it does mean people are pushed towards things that will *actually* cure them because it's cheaper in the long run!)

I have many relatives and friends who've suffered with depression and can say with confidence that without the talking, the depression never truly goes away, but without the drugs, the fog is often too dark to begin the talking process.

I think there are cases where that's true EVEN IF the root cause is, as we might say, theological - a messed up view of God, or unconfessed sin, or such like.

I wonder whether a better analogy than ill-fitting shoes might be someone who's waiting for surgery on a slipped vertebral disc. Yes, their ultimate need is for the actual healing, but we wouldn't deny them painkillers in the meantime.

Anyway, just a thought. As I said above, I love the care you've taken not to use broad brush strokes. So many Bible-loving Christians can be glib about the causes of depression and you have been so careful not to be, and, for all I often find myself disagreeing with this blog, I'm not such a blind leftist that I can't recognise the spiritual fruit of Gentleness when I see it.

Most helpful. The majority of men who come from detox to our discipleshjp program b/c of substance abuse have been prescribed some sort of anti-depressants. I've never heard of one who asked for or was given answers to the questions you suggest. Will definitely come in handy on a weekly basis for me.

I also agree and have personally experienced running into the "No meds, just bible" ditch. That is common in our particular fundamental camp.

Thanks for the succinct and thoughtful post. May God continue to bless your service to Him.

Great post. My mother-in-law takes one of the popular anti-depressants (Zoloft maybe) and tried to go cold turkey...she wound up in some pretty foul moods and has gone back to taking them. Our pastor told her she needed to wean herself off of them, but she didn't. And now I think she is scared to even try that. I might pass this along to her and see if she feels comfortable talking to her doctor about it.

I think that you are correct Dan. I believe that it is a mix of physical and nonphysical. Christians are often to quick to dismiss the physical element. Personally, I have found that the physical element predisposes me to depression. Spiritual issues push me into it.

Recently read a book that was a breath of fresh air. "Counseling the Hard Cases" by Scoot, Lambert and MacArthur. I do not remember where they came down on meds, but I suspect they would agree with Dan's post completely. It was refreshing to see the Bible as integral and prominent in treatment.

This was a timely post for me. We have a college-age son who is mildly autistic and struggles with depression. It has become so severe that we are taking a leave of absence and returning to the US this weekend to try to help him get better.

Honestly, we are so deep in boxes and suitcases right now that I could only skim through the highlights, but I'll certainly be re-reading this later. You hit on some of the issues that most concern us--namely, understanding what aspects of his depression are spiritual and which are related to autism, and addressing both.

I suffered from depression for decades before God brought me into His family. One of the changes, not surprisingly, was an improved outlook, but there were still times when I got very low.

Prozac was still the new "wonder drug," and I started taking it a few months after becoming a believer. It took 10 days to "kick in," but the effect was startling. I remember thinking, "Oh, this is how normal people feel." I wasn't euphoric; it was more that the lows were leveled off and that I increasingly took life as it came.

I don't recall anyone telling me, "If you had more faith, you wouldn't have needed the drug," but I wouldn't have been surprised if anyone thought that. Of course, it's possible that's true, but I tend to doubt it. Apparently, I had/have a chemical (serotonin) deficiency that was clearly helped by the drug.

Something that is often overlooked on the physical side is exercise and diet. Those two things can have a dramatic effect on a person's mental wellbeing. But I suspect it's a bit harsh to tell somebody they should start with dropping lbs and running 2 miles a day. But drugs simply cannot make up for this deficiency.

Thanks for your caring and compassionate approach to this complex question, Dan. I deeply appreciate your sensitivity and yet also your courage to press these important questions.

I'm probably a bit more optimistic about anti-depressants than you are, especially in cases where they help a severely depressed person get to a place where they can begin to process thoughts, speak, and listen rationally again.

But I do share your concerns as well.

Here are some principles I try to operate by:

1. Don't run to medication as a first port of call (the most common problem in the USA).2. On the other hand, don't rule out medication either. You may be refusing a good gift of God in your case.3. Don't wait too long to consider meds as sometimes the longer you wait the harder it can be to recover.4. Remember the impact of your depression on others. It's all very well to have a personal determination to tough it out without meds, but in the meantime your loved ones may be suffering greatly through your (proud?) selfishness. 5. Never rely on meds alone. I have never seen anyone recover from depression who relied on pills alone. If used, meds should always be part of a holistic care package that includes your pastor, Christian fellowship, recreation, rest, diet, sleep, etc.

About 10 years ago I went into a severe depression. I resisted medication, believing I should try to rely on God alone. I was struggling to get out of bed every day, crying a lot, and the pain was so bad that while I didn't seriously contemplate suicide - I did think that if I had to go on feeling this way life would be unbearable.

A dear friend encouraged me to try medication because of David's point 4. I had a husband and three sons to look after. My illness had a great impact on them.

After 2 weeks on medication I began to feel like my old normal self. I didn't feel any of the things suggested in the original post. I felt normal emotions of sadness and happiness. I was not numbed or felt that the medication masked all my problems. Perhaps that is not everyone's experience.

I was on medication for a year after which I followed the doctors instructions on slowly coming of them. All the time I was on meds I followed David's point 5. I exercised daily, watched my diet, sought to deepen my relationship with God. Taking the medication enabled me to be in a place where I could do these things.

I have not had a relapse in 10 years - I did not have to keeping increasing the dosage of medication.

I just wanted to give one example (I know every case is different) where medication played a part - a big part but still just a part, in a recovery from depression which was helpful.

I'm behind in my reading, which explains this late comment. I know this may sound strange, but I'm thankful that the God of the universe saw fit to create you in such a way that you struggle in this area. Your strong theological positions combined with your understanding of this subject personally combined with the humility of recognizing that there is some aspects of it you don't know or understand add up to a pastoral heart of compassion that is very helpful to others.

I have a friend who sometimes struggles with anxiety and panic attacks, and my lack of personal experience and my strong views about sin and its consequences makes it difficult for me to be compassionate. Sometimes I say things that are helpful and encouraging, sometimes I'm not so sure.

2. It sounds like one of the main things you're arguing against is chemical imbalance theories for depression. Arguing against or at least highly suspect of the idea that depression is caused by low levels of serotonin in the brain. I agree there are problems with chemical imbalance theories including the serotonin one. But I don't think this means we should throw out the baby with the bath water.

3. You mention: "I talked to my doctor about the very serious depression I was beginning to experience some decades ago, he told me about the lack of serotonin in my brain, and wanted me to take a pill for it." Obviously a lot has changed in medicine in "decades." Also, we don't know if he was a psychiatrist.

4. Could I humbly suggest you might be burning a strawman, at least in the following respects?

a. To my knowledge and in my experience, many if not most physicians are quite aware our understanding of depression is incomplete. I think the article and video you cite are indicative of this.

b. Many if not most physicians are aware of various theories for depression including low serotonin levels. But again to my knowledge and in my experience I don't know a single contemporary physician who believes low serotonin levels are the be-all and end-all to explaining depression. Many if not most seem to think there could be a number of factors involved.

Take modern psychiatrists. They consider various models including the "bio-socio-psycho-spiritual" model. They'll try to figure out if the person's condition could be due in part or entirely to biological factors (e.g. hypothyroidism, genetic conditions). Also they'll try to see if there are social factors in the person's life to consider (e.g. stressful job, abusive relationships, financial trouble). They'll ask if there are psychological factors involved (e.g. suicidal ideation). And they'll query a person's religious or related beliefs. They're trained to consider the whole person.

c. Indeed, there's quite a bit of debate among psychiatrists over the American Psychiatric Association's recently published DSM-V including over criteria for clinical depression.

d. I don't think it's true, but say it's true most physicians subscribe to the serotonin theory. Nevertheless I would think many if not most understand there's a tremendous difference between correlation and causation.

e. Related, I seriously doubt most physicians would say "mental issues, emotional issues, behavioral issues" are "cut and dried." In fact, we're explicitly taught in med school and explicitly told by doctors in the various hospitals and wards we're required to rotate through that mental issues are anything but. We're explicitly told how mental issues are so difficult and complex to pin down, how ill-defined they are, etc. Indeed, this is one reason why most med students don't wish to go into fields like psychiatry and neurology, because these fields are regarded as less "cut and dried" than other fields in medicine, and most med students seem to tend to prefer fields where there are more concrete diagnoses, treatments, and the like.

5. I could be mistaken, but I suspect to the extent people think "the lack of serotonin" in one's brain is what causes depression is more something large swathes of the media has perpetuated than what doctors today generally subscribe to. For instance there are some studies which have shown selective serotonin reuptake inhibitors (SSRIs) have been successful in treating depression in HIV positive patients. The media could easily take this to indicate serotonin deficiencies cause depression. But physicians know this doesn't mean we should therefore extrapolate from these studies to say SSRIs always work for treating all depressed patients. After all, there could be many other reasons why SSRIs worked in these HIV positive patients which can't be applied to other sorts of patients.

6. A lot hinges on what we mean by depression. For what it's worth, psychiatrists generally classify depression into at least four groups:

a. Adjustment disorder with depressed mood. Depression occurring in reaction to an identifiable stressor or adverse life situation (e.g. death of a loved one, divorce, financial crisis).

b. Mood disorders secondary to illness and medications. Depression as a result of conditions like arthritis, stroke, alcoholism, drugs, etc.

c. Bipolar disorders. There are two subcategories here: mania and cyclothymic disorders. A manic episode is a mood change characterized by elation with hyperactivity, flights of ideas, distractibility, little need for sleep, among others, which swings into depression, anger, aggressiveness, and so forth. Cyclothymic disorders are chronic mood disturbances with episodes of depression and hypomania.

d. Depressive disorders. There are three subcategories here: dysthymia; premenstrual dysphoric disorder; and major depressive disorder. Dysthymia is chronic depressive disturbance generally milder but longer lasting than major depressive disorder. Premenstrual dysphoric disorder is depression as a result of the menstrual cycle. Finally, major depressive disorder has three further divisions: major depression with atypical features; seasonal affective disorder; and postpartum depression.

For example, take postpartum depression. It seems uncontroversial to say hormonal changes and psychosocial stressors in the life of a woman who has recently given birth play large roles in postpartum depression. So this sort of depression would have an arguably strong connection to the physiological (hormonal changes). A doctor might try to treat her postpartum depression with non-pharmacological methods (e.g. psychotherapies), but I don't see that there's anything askew about considering hormonal treatment to better regulate her hormones as part of the arsenal.

a. Tests can be used for different purposes. For example, there's a difference between using a test for screening and using it for diagnosis.

b. Tests have their limitations. Some tests are more (or less) accurate at finding what they're supposed to find than other tests. Just Google sensitivity and specificity of tests for starters.

c. Tests are only able to find what they're designed to find. Nothing less, nothing more. A chest x-ray is useful for identifying pneumonia, but not useful in identifying brain cancer. An EKG is useful for identifying electrical abnormalities in the heart, but not useful in identifying kidney disease.

d. Some diseases or conditions don't need tests to be diagnosed. It doesn't take a test to diagnose that someone has been stabbed if someone presents with, say, a bleeding wound and says he got into a fight and has been stabbed. A test could be used to see where the knife punctured or where to operate. But it'd be superfluous to order a test to confirm they've been stabbed.

Or to take a more mundane example, physicians don't really need to order a test to diagnose the common cold. It can be done based on the patient's history and/or a quick physical examination. Their signs and symptoms usually say it all.

e. As for depression. The diagnosis of a depressive episode includes determining the psychiatric category and determining if the etiology is idiopathic or related to an underlying systemic or neurologic condition, substance use, or prescription medication side effect.

f. The diagnosis of depression is largely based on patient history and mental status examination. Also, there's usually an evaluation for suicide risk. And a patient history would normally include a comprehensive medical history, exploration of comorbid psychiatric disorders like substance use, and of course a family history.

g. There's no evidence to support routine laboratory testing in the diagnosis of depression. However, a complete blood count, a basic chemistry profile, liver function tests, TSH, RPR, B12, and folate levels are helpful when underlying medical conditions are suspected.

8. I would think most people don't directly see a psychiatrist. Rather I would think most people are probably referred to a psychiatrist by another physician. Generally speaking, a referral to a psychiatrist most likely means the referring physician thinks the person's illness would be best suited for a psychiatrist to treat or manage. This in turn could quite possibly mean a physician has already tried to address non-psychiatric aspects of the person's illness. In short, psychiatrists are generally consulted primarily for psychiatric and related concerns, not for non-psychiatric concerns.

9. Richard Winter over at Covenant Seminary seems to be a good Christian psychiatrist.

Depression comes with a liability for those who treat it. A doctor or a counselor can be sued for not treating a potential physical problem that can result in suicide. If it's complex enough not to know to what extent the physical plays, then treating the physical is prudent. If the issue isn't physical, then treating the physical will have no bearing on the outcome. In either case, good counsel is necessary.

Thanks for the post, and as others have said excellently reasoned and compassionately presented. One book that I found immensely helpful in navigating this issue and others from a biblical perspective, is Ed Welch's, Blame It On the Brain?.

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